the nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1 year old grandchild wh
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

Correct answer: C

Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.

2. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct answer: D

Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.

3. A client with hypertension is prescribed atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

Correct answer: D

Rationale: Correct. Bradycardia is a known adverse effect of atenolol, a beta-blocker medication commonly used to treat hypertension. Atenolol can slow down the heart rate, leading to bradycardia. The nurse should monitor the client for signs of bradycardia, such as dizziness, fatigue, or fainting. Choices A, B, and C are incorrect because cough, tremor, and constipation are not typically associated with atenolol use.

4. Which action by the nurse represents the ethical principle of beneficence?

Correct answer: B

Rationale: The correct answer is B. Beneficence is the ethical principle of doing good or acting in the best interest of the client. Preventing harm by providing accurate information and necessary care aligns with the principle of beneficence, as it focuses on promoting the well-being and safety of the client. Choices A, C, and D do not directly reflect the concept of beneficence. Ensuring all clients are treated fairly relates more to justice, allowing the client to refuse treatment pertains to autonomy, and ensuring the client's family agrees with the treatment involves collaboration and communication but not specifically beneficence.

5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

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